1639103062 NPI number — KURT ROBERT ERIK MADSEN D.O.

Table of content: KURT ROBERT ERIK MADSEN D.O. (NPI 1639103062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639103062 NPI number — KURT ROBERT ERIK MADSEN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADSEN
Provider First Name:
KURT
Provider Middle Name:
ROBERT ERIK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639103062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 E HOSPITAL LN
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47802-4230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-234-2663
Provider Business Mailing Address Fax Number:
812-242-5878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 E HOSPITAL LN
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-4230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-2663
Provider Business Practice Location Address Fax Number:
812-242-5878
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  02001875 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000577747 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200217870 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000490011 . This is a "BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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